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Guidelines for the management of symptomatic sexually transmitted infections [Internet]. Geneva: World Health Organization; 2021 Jun.

Cover of Guidelines for the management of symptomatic sexually transmitted infections

Guidelines for the management of symptomatic sexually transmitted infections [Internet].

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ANNEX 3EVIDENCE-TO-DECISION TABLE: URETHRAL DISCHARGE

Should current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify STIs among men with urethral discharge or persistent or recurrent urethral discharge?

Population

Men with urethral discharge

Intervention and comparator

Current WHO syndromic approach versus laboratory diagnosis (or no treatment or treat all)

Purpose of the approach

To identify men for treatment of STIs

Linked treatments

Treatments for infections caused by N. gonorrhoeae, C. trachomatis, T. vaginalis and M. genitalium

Anticipated outcomes

Number of people identified correctly as having or not having STI; number of people identified incorrectly as having or not having STI; consequences of appropriate or inappropriate treatment; patient and provider acceptability, feasibility, equity and resource use

Setting

Outpatient

Perspective

Population level

Subgroups

High- or low-prevalence settings; settings with limited versus established laboratory capacity

Background

Syndromic management refers to a strategy for identifying and treating STIs based on specific syndromes (symptoms identified by a patient) and signs (clinically observed signs of infection) associated with clearly defined causes. Although etiological diagnosis is preferred, it is not always accessible or affordable.

Fig. A3.1 provides clinical guidelines for the syndromic management of urethral discharge and persistent or recurrent urethral discharge in the 2003 WHO publication Guidelines for the management of sexually transmitted infections.

Assessment

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Summary of judgements

Judgement
ProblemNoProbably noProbably yesYesVariesDon’t know
Test accuracyVery inaccurateInaccurateAccurateVery accurateVariesDon’t know
Desirable effectsTrivialSmallModerateLargeVariesDon’t know
Undesirable effectsLargeModerateSmallTrivialVariesDon’t know
Certainty of the evidence of test accuracyVery lowLowModerateHighNo included studies
Certainty of the evidence of the effects of managementVery lowLowModerateHighNo included studies
Certainty of effectsVery lowLowModerateHighNo included studies
ValuesImportant uncertainty or variabilityPossibly important uncertainty or variabilityProbably no important uncertainty or variabilityNo important uncertainty or variability
Balance of effectsFavours the comparisonProbably favours the comparisonDoes not favour either the intervention or the comparisonProbably favours the interventionFavours the interventionVariesDon’t know
Resources requiredLarge costsModerate costsNegligible costs and savingsModerate savingsLarge savingsVariesDon’t know
Certainty of evidence of required resourcesVery lowLowModerateHighNo included studies
Cost- effectivenessFavours the comparisonProbably favours the comparisonDoes not favour either the intervention or the comparisonProbably favours the interventionFavours the interventionVariesNo included studies
EquityReducedProbably reducedProbably no impactProbably increasedIncreasedVariesDon’t know
AcceptabilityNoProbably noProbably yesYesVariesDon’t know
FeasibilityNoProbably noProbably yesYesVariesDon’t know

Conclusions

Should current WHO syndromic management be recommended versus laboratory diagnosis, no treatment or treat all to identify STIs among men with urethral discharge or persistent or recurrent urethral discharge?

Type of recommendation

○

Strong recommendation against the intervention

○

Conditional recommendation against the intervention

○

Conditional recommendation for either the intervention or the comparison

○

Conditional recommendation for the intervention

●

Strong recommendation for the intervention

Recommendation

Recommendations for the management of urethral discharge

For people with symptom of urethral discharge from the penis, management is recommended to be based on the results of quality-assured molecular assays. However, in settings with limited or no molecular tests or laboratory capacity, we recommend syndromic treatment to ensure treatment on the same day of visit.

Good practice includes:

  • taking a medical and sexual history and assessing the risk of STIs;
  • performing a physical examination of the genital and anal areas; and
  • offering HIV and syphilis testing and other preventive services as recommended in other guidelines.

Settings with quality-assured molecular testing in a laboratory with a fully operational quality management system and results available on the same day of the visit.

We recommend the following.

  1. Perform molecular assays such as nucleic-acid amplification test (NAAT) to confirm or exclude Neisseria gonorrhoeae and Chlamydia trachomatis.
  2. Treat according to the test results on the same day. If urethral discharge is present but tests are negative, treat for non-gonococcal and non-chlamydial urethritis (such as Mycoplasma genitalium or Trichomonas vaginalis).
  3. When treatment based on molecular assays is not feasible on the same day of the visit, we recommend syndromic treatment of infection with N. gonorrhoeae and C. trachomatis and use the test results to support managing the partner when tests are available.
  4. Treat people with recurrent or persistent urethral discharge based on a repeat molecular assay (such as NAAT) after 21 days, testing for N. gonorrhoeae, C. trachomatis as well as M. genitalium and T. vaginalis and test for antimicrobial-resistant N. gonorrhoeae.

Settings in which same-day treatment is not feasible with molecular testing or with limited or no molecular testing.

We suggest the following.

  1. Treat people who have urethral discharge confirmed on examination for N. gonorrhoeae and C. trachomatis to ensure same-day treatment.
  2. Treat people with recurrent or persistent urethral discharge for treatment failure based on WHO guidelines and review.

Good practice includes:

  • if symptoms persist at review, checking partner notification and treatment history; and
  • for people with recurrent or persistent urethral discharge, referring people to a centre with laboratory capacity to diagnose N. gonorrhoeae, C. trachomatis, M. genitalium and T. vaginalis and to test for antimicrobial-resistant N. gonorrhoeae and M. genitalium.

Justification
  • Adding microscopy did not improve the sensitivity and specificity of the flow chart.
  • Studies show variability in the implementation of syndromic approaches based on symptoms or laboratory testing, and a simple management approach could lead to better implementation.
  • Performing molecular assay tests for N. gonorrhoeae, C. trachomatis and T. vaginalis and/or M. genitalium and basing treatment on these results leads to the most people treated correctly.
  • In a population with 60% prevalence of N. gonorrhoeae and C. trachomatis among those with urethral discharge, treating all for N. gonorrhoeae and C. trachomatis would mean that 40% of people would be unnecessarily treated. The Guideline Development Group agreed that this proportion is acceptable, as are higher proportions in lower-prevalence settings, because treating all would ensure that people with N. gonorrhoeae and C. trachomatis are treated, thereby reducing the chance of complications and further transmission.
Fig. A3.1. Current WHO syndromic approach to the management of urethral discharge.

Fig. A3.1Current WHO syndromic approach to the management of urethral discharge

Fig. A3.2. Current WHO syndromic approach to the management of persistent or recurrent urethral discharge.

Fig. A3.2Current WHO syndromic approach to the management of persistent or recurrent urethral discharge

References

1.
Bhavsar C, Patel RM, Marfatia Y. A study of 113 cases of genital ulcerative disease and urethral discharge syndrome with validation of syndromic management of sexually transmitted diseases. Indian J Sex Transm Dis AIDS. 2014;35:35–9. [PMC free article: PMC4066595] [PubMed: 24958984]
2.
Chandeying V, Skov S, Tabrizi SN, Kemapunmanus M, Garland S. Can a two-glass urine test or leucocyte esterase test of first-void urine improve syndromic management of male urethritis in southern Thailand? Int J STD AIDS. 2000;11:235–40. [PubMed: 10772086]
3.
Liu H, Jamison D, Li X, Ma E, Yin Y, Detels R. Is syndromic management better than the current approach for treatment of STDs in China? Evaluation of the cost–effectiveness of syndromic management for male STD patients. Sex Transm Dis. 2003;30:327–30. [PubMed: 12671553]
4.
Tsai CH, Lee TC, Chang HL, Tang LH, Chiang CC, Chen KT. The cost–effectiveness of syndromic management for male sexually transmitted disease patients with urethral discharge symptoms and genital ulcer disease in Taiwan. Sex Transm Infect. 2008;84:400–4. [PubMed: 18426845]
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Wang Q, Yang P, Zhong M, Wang G. Validation of diagnostic algorithms for syndromic management of sexually transmitted diseases. Chin Med J (Engl). 2003;116:181–6. [PubMed: 12775225]
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Yu MC, Li LH, Lu TH, Tang LH, Tsai CH, Chen KT. Aetiology of sexually transmitted disease (STD) and comparison of STD syndromes and aetiological diagnosis in Taipei, Taiwan. Clin Microbiol Infect. 2005;11:914–8. [PubMed: 16216108]
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Leichliter JS, Paz-Bailey G, Friedman AL, Habel MA, Vezi A, Sello M et al. “Clinics aren’t meant for men”: sexual health care access and seeking behaviours among men in Gauteng province, South Africa. Sahara J. 2011;8:82–8. [PubMed: 23237685]
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Kohler PK, Marumo E, Jed SL, Mema G, Galagan S, Tapia K et al. A national evaluation using standardised patient actors to assess STI services in public sector clinical sentinel surveillance facilities in South Africa. Sex Transm Infect. 2017;93:247–52. [PubMed: 28130505]
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Grosskurth H, Mwijarubi E, Todd J, Rwakatare M, Orroth K, Mayaud P, et al. Operational performance of an STD control programme in Mwanza Region, Tanzania. Sexually Transmitted Infections. 2000;76(6):426–36. [PMC free article: PMC1744245] [PubMed: 11221123]
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Khan AA, Khan A. Sexually transmitted infection care in Pakistan: the providers’ perspective. J Pak Med Assoc. 2012;62:941–5. [PubMed: 23139980]
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Iipinge SN, Pretorius L. The delivery and quality of sexually transmitted infections treatment by private general practitioners in Windhoek Namibia. Glob J Health Sci. 2012;4:156–71. [PMC free article: PMC4776997] [PubMed: 22980389]
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Weaver MR, Pillay E, Jed SL, De Kadt J, Galagan S, Gilvydis J et al. Three methods of delivering clinic-based training on syndromic management of sexually transmitted diseases in South Africa: a pilot study. Sex Transm Infect. 2016;92:135–41. [PMC free article: PMC4783332] [PubMed: 26430128]
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Hoffman CM, Fritz L, Matlakala N, Mbambazela N, Railton JP, McIntyre JA et al. Community-based strategies to identify the unmet need for care of individuals with sexually transmitted infection-associated symptoms in rural South Africa. Trop Med Int Health. 2019;24:987–93. [PubMed: 31141301]
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Aaron K, Jordan S, Schwebke J, Van Der Pol B, Hook E. Continued sexual activity following onset of urethritis symptoms in men. Sex Transm Dis. 2018;45(Suppl. 2):S38.
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Ham DC, Hariri S, Kamb M, Mark J, Ilunga R, Forhan S et al. Quality of sexually transmitted infection case management services in Gauteng Province, South Africa: an evaluation of health providers’ knowledge, attitudes, and practices. Sex Transm Dis. 2016;43:23–9. [PMC free article: PMC6756471] [PubMed: 26650992]
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Alemayehu A, Godana W. Knowledge and practice of clinicians regarding syndromic management of sexually transmitted infections in public health facilities of Gamo Gofa Zone, South Ethiopia. J Sex Transm Dis. 2015;2015:310409. [PMC free article: PMC4641938] [PubMed: 26605102]
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Hussain MF, Khanani MR, Siddiqui SE, Manzar N, Raza S, Qamar S. Knowledge, attitudes & practices (KAP) of general practitioners (GPS) regarding sexually transmitted diseases (STDS) and HIV/AIDS in Karachi, Pakistan. J Pak Med Assoc. 2011;61:202–5. [PubMed: 21375183]
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Table A3.4Studies included in the diagnostic accuracy of syndromic approaches to urethral discharge

StudyCountryDesign n STI prevalenceSettingPopulation (age group)Flow chart description(s)Reference test(s)
Bhavsar et al. (1)IndiaCross-sectional17N. gonorrhoeae: 88.2Hospital skin and venereal disease outpatient department

General population men

(15–70 years)

History, risk assessment and genital examinationN. gonorrhoeae: Gram stain
Chandeying et al. (2)ThailandCross-sectional129

N. gonorrhoeae: 32.6;

C. trachomatis: 23.3;

STI units

General population men

(mean and median age = 30 years)

History, risk assessment and genital examination plus microscopy

N. gonorrhoeae: culture and/or PCR

C. trachomatis: PCR

Liu et al. (3)ChinaCross-sectional347

N. gonorrhoeae: 61.1

C. trachomatis: 23.6

N. gonorrhoeae or C. trachomatis: 69.2

STD clinics

General population men

(18–83 years)

History and risk assessmentN. gonorrhoeae or C. trachomatis: PCR
Tsai et al. (4)TaiwanCross-sectional335N. gonorrhoeae or C. trachomatis: 40.6STD clinic, genitourinary outpatient clinic

General population men

(17–50 years)

History, risk assessment and genital examinationN. gonorrhoeae or C. trachomatis: PCR
Wang et al. (5)ChinaCross-sectional325

N. gonorrhoeae: 64.3

C. trachomatis: 16.3

N. gonorrhoeae or C. trachomatis: 72.6

Urban STD clinics

General population men

(16–63 years)

History, risk assessment and genital examination plus microscopy for Gram staining

N. gonorrhoeae: Gram stain + culture

C. trachomatis: PCR

Yu et al. (6)TaiwanCross-sectional307

N. gonorrhoeae: 10.1

C. trachomatis: 14.3

STD Control Center clinic

General population men

(16–50 years)

History, risk assessment and genital examinationN. gonorrhoeae/C.trachomatis: PCR microscopy plus culture
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